back Pain

Back Pain: Perspectives from an Integrative Medical Doctor

by Astrid Pujari, MD, RH(AHG)

Low back pain is a common problem in primary care. It is the fifth leading cause of medical office visits in the United States, and the number one cause of work-related disability. Although back pain usually originates from musculoskeletal disorders, it can also originate from serious pathologic problems, which are important to evaluate using allopathic medicine.

Unfortunately, standard allopathic medicine often focuses exclusively on the use of prescription drugs andthe mechanics of body functioning. This usually occurs at the expense of natural approaches, which can often behelpful, including herbs. Allopathic medicine also frequently neglects the spiritual component of illness,which in my opinion, is essential to address because it can lead to tremendous benefits in the client's quality of life.

While it is fairly straight forward to review the basic approach to low back pain from an allopathicperspective, it can be challenging to simplify holistic and spiritual diagnosis and treatment into an algorithm,because the latter are often tailored to the individual. In this article, I will use a case to describe an integrativemodel I have developed for approaching patients with many problems, including back pain. Using thismethod, I begin with the client's symptoms. I explain how those symptoms would be assessed and treatedthrough the eyes of three different paradigms: allopathic medicine, holistic medicine, and spiritually-basedhealing. The client, with guidance from the practitioner, chooses the treatment options from the models that suitthem best. This leads to a tailored, individualized plan.

Allopathic Diagnosis From a medical perspective, the differential diagnosis for low back pain can be divided into three categories; mechanical low back pain, non-mechanical back pain, and referred pain.

Mechanical low back pain, the most common type, originates from problems with the "mechanics," oranatomical functioning of the back. Infection, malignancy involving the spine, and inflammatoryarthritis, such as ankylosing spondylitis, are not considered mechanical pain because the pathophysiologyof these diseases is inflammatory in origin. They are categorized as non-mechanical back pain.

Referred pain evolves from an area of the body other than the back, such as the aorta, the kidneys, or other organs. When evaluating someone with back pain, the first and most important concern is to be sure that they do not have "alarm symptoms" suggesting a serious condition such as cancer or infection, requiring immediate medical attention. Alarm symptoms include severe, constant pain that does not improve with lying down, pain that is worse at night, leg weakness, loss of stool, new sexual dysfunction, or new incontinence. Furthermore, any clients with fever, infection including urinary tract infection, weight loss, age greater than 50 years old, symptoms that do not resolve, history of cancer, drug use, extreme stiffness, and immunosuppression have an increased risk of serious underlying illness.

Differential Diagnosis

The differential diagnosis of mechanical low back pain is extensive. The four most common causes are lumbar strain, which accounts for about 70% of cases, degenerative disease, disk herniation, and spinal stenosis.

Lumbar strain generally presents as a nonspecific aching pain in the lumbar area of the back, which gets worse with rest. Risk factors for developing lumbar strain include smoking, poor muscle tone, obesity, and certainactivities, such as repetitive lifting.

Spinal stenosis usually presents as pain in an elderly client that radiatesfrom the lumbar spine down to the buttocks and thighs, and is worse with activity, especially when standingstraight. Classically, the pain will improve when leaning forward, such as over a shopping cart. Degenerativedisease of the vertebral disks and bones of the posterior spine, including osteoarthritis, is a common cause ofpalm in older adults. Depending on the person, it can present with features of lumbar stenosis, lumbar strain, or nerve impingement.

Disk herniation classically results in shooting, sharp, or burning pain in a dermatomal distribution. A dermatome refers to the area innervated by nerves emanating from a single nerve root in the spinal cord.Pain occurs because the extruded disk material impinges on the nerve root and also causes inflammation. Themost common roots involved include L4, L5 and S1. Because a herniated disk prevents the nerve root frommoving easily, straightening the leg usually elicits pain. This is the basis for the straight leg test.

The term "sciatica" is used to refer to pain that radiates along the sciatic nerve, which originates fromthe L5 and S1 nerve roots. This pain is usually burning or shooting, begins in one of the buttocks, and ofteninvolves the posterior thigh and calf. Although sciatica frequently develops from a herniated disk, this is not theonly cause. The differential diagnosis also includes muscular entrapment, and spinal stenosis (also known aslumbar stenosis). However, approximately 95% of patients with a herniated disk will have sciatic symptoms and most patients with sciatica have a herniated disk; if is therefore helpful to elicit these symptoms to narrowdown the differential diagnosis of the client's back pain.

Holistic Approach

A holistic approach has much to offer clients with back pain. Proper lifestyle is essential for natural therapies to work, and in fact, many problems will resolve simply by doing the things we all know are good for us. This includes proper amounts of rest, exercise, stretching, prayer, and a healthy diet, rich in organic, wholefoods, fruits and vegetables, and water. However, they are many specific holistic remedies that can be helpful for patients as well. We will not review all of them here, but I will discuss those that were relevant to this woman'sCase.

Calcium and magnesium can also be helpful, either through food, herbs or supplements.Bromelain, also is recommended, a group of proteolytic enzymes derived from pineapple. I have found it effective for muscle soreness, pain and swelling. Clinical trials, however, do not clearly support this. Although some data suggests it might act as an anti-inflammatory, other trials question whether sufficientamounts reach the muscles to explain its effects."

Herbs can be used in two ways to promote healing, although there is of course, overlap. The first focusesprimarily on the physical properties of herbs. In this case, the emphasis is frequently on plant constituents, andrelevant physical actions - antispasmodic, anti-inflammatory, anodyne, etc. Proponents exclusively ofthis system will often equate the actions of a plant exclusively to its physical properties. The ocher approachfocuses on the energetic actions of a plant. Personally I believe that both viewpoints can be helpful at different times, depending on the individual case.

Disclaimer: I, (Teresa Biggins) am not a Medical Doctor, and cannot prescribe, cure or diagnose. Many of these articles have not been written by me. They have been copied , usually word for word from Web sites, periodicals, books and fliers. Not all agree with my position concerning some issues, but they are all excellently written with wonderful information in them. It is only by studying many positions that we can make OUR OWN informed decisions. The articles are gathered and presented this way in order to help you achieve that end easier. Full credit and the source is always given, and I encourage you to look the sources up, as most may have additional information. ALL information on any page is here for furthering your educational needs for the purpose of equipping you with information only, and not intended for prescribing, diagnosing, or curing any ailment you may have. These articles may not be misconstrued as medical advise or instruction. No action should be made based solely on these contents; instead readers should contact the appropriate health practitioner on any matter relating to their health, or well being. Readers who fail to consult with with appropriate health professionals assume the risk of any injury. Your body is your own to care for. No claims can be legally made about the information supplied on these pages. These instructional documents have been prepared as a narration or copy of what has been reported in the most effective way to use the product or gain knowledge about specific subjects or products. These are not endorsed by the AMA or the FDA. All are intended to be an honest report of what is known about these subjects for those who are interested.